Provider Demographics
NPI:1457443624
Name:VICTORY ORTHOTICS & PROSTHETICS LLC
Entity Type:Organization
Organization Name:VICTORY ORTHOTICS & PROSTHETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-864-8790
Mailing Address - Street 1:102 WOODMONT BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37205-5249
Mailing Address - Country:US
Mailing Address - Phone:615-550-8774
Mailing Address - Fax:156-454-5352
Practice Address - Street 1:2333 KNOB CREEK RD STE 14
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-461-3320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9190601Medicaid
TN1454184Medicaid
TN4017529OtherBCBSTN
TN4273920001Medicare NSC